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J R Soc Med. 2007 April; 100(4): 160–161.
PMCID: PMC1847733

The solution to chaos is not chaos

It is difficult to find anyone who has much good to say about Modernising Medical Careers and the Medical Training Application Service process. The process promised:

‘Recruitment and selection will be fair, open and legally robust. Selection methods will be specialty specific, but the minimum requirement will be a formal interview. The methodology is being designed by leading educationalists and recruitment specialists.’1

Earlier documents had also stated:

‘Reform is also about securing our workforce for the future as our medical school output rises and is about giving doctors in training a chance of a fulfilling career to their own and to patients' benefit.’2

And that:

‘It is not acceptable that they should at this stage fall out of the training system.’2

So why has it gone wrong and why have so many junior doctors have lost confidence in the system? The system was introduced hurriedly; juniors saw the rules changing by the week and saw their options become ever more limited as they waded through the online instructions. Perhaps the Department of Health's touching faith in computerized systems added to the problems that were, by and large, predictable. With over 30 000 applicants, the system was flooded. Predictably, it crashed or froze while so many struggled to get their applications in. Most of the applications were not completed in working hours—the junior doctors were far too busy looking after patients—so peak usage occurred on Sunday evenings. Then the online short listing systems failed, so forms were printed off and scored. This removed the quality assurance step of one assessor scoring the same question on every form, and the requisite secondary scoring of about 10% of forms to detect hawks and doves in the scorers did not happen across the board. Some forms reportedly were missed altogether, and for others the paper score was not transferred to the website. Initial undertakings that every form would be scored twice did not materialize.

But how secure is online scoring anyway? Could anyone with a password get online and alter a score? At least there are no reports of hackers getting to the website applications. Of course, even perfect short listing procedures require that the form was initially filled in by the applicant alone and reflects their own work. But early panic fuelled ‘ghost writer’ commerce, with rumours that the ‘going rate’ was £15 per question or £250 per form to be filled in in such a way as to slip past the plagiarism software: rumour has it that the cost of a model answer has now risen to £600. Short listing picked up some of these, spotting remarkable similarities in case descriptions.

Co-ordination of interview dates across the country failed, so that doctors could not attend interviews in all the Deaneries that selected them. Some interview panels have seen doctors who should never have got to interview because the long-listing process to check basic qualifications has been by-passed, probably due to pressures of time, more applications than anticipated and too few administrative staff. Deaneries are now so bowed down that some are refusing to answer the phone, and one interview panel was so disillusioned that they refused to proceed, despite one applicant having travelled from New Zealand for interview.

Some excellent doctors see their dreams in tatters; despite years of work and higher exams they have not had a single interview. They have no faith in ‘the system’ and see unemployment looming.

This is disastrous. The Minister, Lord Hunt, is right to demand immediate remedial action and is right to continue with the process that has started. To abandon it now would be to abandon all those applicants who are part way through the process, and to abandon restorative justice for those not yet short listed but whose forms are being rescored. Time is on the side of MTAS. Much work has been put in to the benefit of training—job profiles and person specifications are standardized, entry criteria for training grades are better defined than before and the use of questions about experience attempt to clarify much that is absent from a curriculum vitae or an NHS Trust application form. The interviews of multiple stations should allow candidates flexibility to demonstrate skills, avoiding the drift in bias within the 30 minute single interview. How often has an excellent but nervous candidate dug a hole ever deeper in interview, never to recover, or a charmer wooed a committee?

The most important step towards restorative justice has been taken by rescoring the forms of all those not short listed, but CVs also need to be looked at. Good candidates must be able to enter the process for interview, effectively starting a second round immediately. The planned second round must become a third round. Interview panels need to scrutinize portfolios with care. The poor wording of the online reference form and the inability of a referee to correct the form after submitting it means the interview panel also need to collate any additional information such as a referee's correction note.

Single transferable voting systems have been deemed too complicated for national elections, so attempts to rank the applicant, merge rankings and produce a single post are over-ambitious and untested. It also removes choice over place of work, as a second choice discipline in an excellent place may be vastly preferred to the discipline listed first. A hierarchy in each discipline and each Deanery would allow juniors some choice if they have done exceptionally well in all their interviews. The idea of only one job offer—‘take it or leave medicine’—treats these applicants as if they are conscripts in the army. These professionals have trained long and hard; an end-stage lottery does nothing to ensure that we are getting the best match of applicants' aptitude to each discipline, for the benefit of patients.

In other walks of life, and in medicine until this year, unsuccessful applicants were allowed feedback. At the end of the process the individual scores should be available, with a possibility to appeal over process. Those whose appeal is upheld must be able to reapply next year without prejudice for the ‘gap’ in their CV, with a guarantee that their forms will be reviewed by an independent scrutineer.

When the Universities Central Council on Admissions was introduced in 1961 there was much concern about its operations; Oxford and Cambridge did not join until 1966 and London medical schools followed a year later. It operated initially with punched cards and despite all its teething and subsequent problems, no-one would advocate returning to multiple individual applications to universities.

This is the first year of a new system and it is flawed. But the old endless, unsynchronized rounds of job applications, with each job having its own application forms, was far from perfect. Doctors in training have shown a great commitment to the NHS; they deserve a fair system to enter higher training and now they deserve restorative justice. Many consultants have worked long and hard to define the job profiles and entry requirements at each level. The Minister is well aware of the crisis; he has personally intervened to take charge, demanding immediate action and a comprehensive review. That review must report fully and openly.

The greatest tragedy of all is that medical unemployment is with us and whatever the appointment system, there are not enough jobs in the long term. Even those that get trained have no assurance of a consultant post at the end of it all. The juniors feel let down by everyone. They will be polled to ascertain their views, but further calls to boycott the system may backfire—our junior doctors deserve training, not chaos.


1. Statement of the four UK Health Departments on transition into specialty training. Modernising Medical Careers. London: Department of Health, 10 March 2007
2. Modernising Medical Careers—The next steps. The future shape of Foundation, Specialist and General Practice Training Programmes. London: Department of Health, April 2004

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press